Can family physicians accurately screen for AAA with point-of-care ultrasound?

Likely yes. Point-of-care ultrasound (POCUS) screening for abdominal aortic aneurysm (AAA) by nonradiologist physicians is 98% sensitive and 99% specific, compared with imaging performed by radiologists (strength of recommendation [SOR]: B, meta-analysis of diagnostic accuracy studies mostly involving emergency medicine physicians). European family physicians demonstrated 100% concordance with radiologist readings (SOR: C, very small subsequent diagnostic accuracy studies).

Evaluation of serum-based real-time PCR to detect Schistosoma mansoni infection before and after treatment.

BACKGROUND: To detect acute schistosomiasis, low-intensity infections, or to verify the success of treatment with praziquantel, highly sensitive test methods are required. The aim of this study was therefore to demonstrate the performance of Schistosoma mansoni specific DNA detection in serum and urine using real-time polymerase chain reaction (PCR) in an endemic area before and after treatment. METHODS: The study pursued a 1-week and 20-weeks longitudinal design with a treatment intervention among 36 study participants aged 18 to 70 years in the community of Kayenze, a fishing village in Ilemela district on the southern shore of Lake Victoria in north-western Tanzania between February and June 2018. Blood, urine and stool samples were collected from each participant to diagnose Schistosoma mansoni infection before and two times after treatment with praziquantel using serum- and urine based real-time PCR, point-of-care circulating cathodic antigen (POC-CCA) rapid diagnostic test and the microscopic Kato-Katz (KK) method. Kappa coefficient (κ) was used to estimate the agreement between these diagnostic tests compared to a combined "gold standard" of positive results by serum-based real-time PCR and/or positive egg counts determined by KK. Kendall's Tau rank correlation was used to examine the relationship between cycle threshold (Ct)-values and egg counts and the Wilcoxon signed-rank test was used to compare the median Ct-values of the different examination time points. RESULTS: By using the combined "gold standard" of the parasitological Kato-Katz test and/or serum-based real-time PCR, a S. mansoni prevalence of 77.1% could be determined at baseline. In terms of sensitivity, serum-based real-time PCR (96.3%) and POC-CCA assay (77.8%) showed the highest results. The detection of DNA from urine samples showed the lowest sensitivity (33.3%). Treatment with praziquantel resulted in a significantly reduced prevalence of S. mansoni. No infection could be detected by Kato-Katz, with the POC-CCA test only 33.3%. The analysis of the median Ct values over time (which were determined by the serum-based real-time PCR) showed that the Ct decreases significantly shortly after treatment (from 30.3 to 28) and increases above baseline level (34.9) three months later. CONCLUSIONS: The data presented here show that the serum-based real-time PCR exhibits excellent diagnostic accuracy, in contrast to the use of urine as sample material for S. mansoni DNA detection. However, as circulating DNA does not necessarily reflect the persistence of living worms in schistosomiasis, this method is less well suited to verify the success of treatment with praziquantel.

Point-of-care used in the treatment of older patients with cancer. The perception and experience of nurses.

BACKGROUND: Nursing tasks are changing as the proportion of people over the age of 65 years is increasing and is expected to double over the next four decades. New innovative solutions such as Point of Care Treatment (POCT) are being tested in oncological settings in order to optimise treatment, and this changes the nurse management in oncology. There is a need to explore oncology nurses' perception and experience when implementing the innovations in order to understand the implications for nursing and the treatment of older patients with cancer. METHODS: Qualitative research with face to face interviews with nurses working in oncology. Sample size (Mean = 8). Data were recorded verbatim, transcribed, and thematic analysis used. RESULTS: Three themes were identified: a, A great advantage in nursing, b, Change of practice in nursing care, c, Challenges in shifting roles. A majority of the participants had the perception that POCT treatment was an advantage not only for the nursing profession but for the older patients in cancer treatment as well. Monitoring the older patients with cancer at home would prevent them from accessing the hospital and get exposed to viral infections as well as saving them the journey to the hospital. Involvement from relatives, clear communication and management of the device and data transferred is essential. CONCLUSIONS: The use of POCT in oncology will shift the nurses' tasks on the ward as well as improve treatment for older patients with cancer.

Rapid point-of-care CD4 testing at mobile units and linkage to HIV care: an evaluation of community-based mobile HIV testing services in South Africa.

BACKGROUND: Mobile HIV testing services (HTS) are effective at reaching undiagnosed people living with HIV. However, linkage to HIV care from mobile HTS is often poor, ranging from 10 to 60%. Point-of-care (POC) CD4 testing has shown to increase retention in health facilities, but little evidence exists about their use in mobile HTS. This study assessed the feasibility of POC CD4 test implementation and investigated linkage to HIV care among clients accepting a POC test at community-based mobile HTS. METHODS: This retrospective study used routinely collected data from clients who utilized community-based mobile HTS in the City of Cape Town Metropolitan district, South Africa between December 2014 and September 2016. A POC CD4 test was offered to all clients with an HIV positive diagnosis during this period, and a CD4 cell count was provided to clients accepting a POC CD4 test. Random effects logistic regression was used to assess factors associated with POC CD4 test uptake and self-reported linkage to care among clients accepting a POC test. Models were adjusted for sex, age, previous HIV test done, tuberculosis status and year of HIV diagnosis. RESULTS: One thousand three hundred twenty-five of Thirty-nine thousand seven hundred ninety clients utilizing mobile HTS tested HIV positive (3%). 51% (679/1325) accepted a POC test. The age group with the highest proportion accepting a POC test was 50+ years (60%). Females were less likely to accept a POC test than males (odds ratio = 0.7, 95%CI = 0.6-0.8). Median CD4 count was 429 cells/µl (interquartile range = 290-584). Among 679 clients who accepted a POC CD4 test, 491 (72%) linked to HIV care. CD4 cell count was not associated with linkage to care. CONCLUSION: Our findings suggest that mobile HTS can identify early HIV infection, and show that a high proportion of clients with a POC test result linked to care. Future research should assess factors associated with POC test acceptance and assess the impact of POC CD4 testing in comparison to alternative strategies to engage HIV positive people in care.

Accelerating availability of clinically-relevant parameter estimates from thromboelastogram point-of-care device.

BACKGROUND: Modeling approaches offer a novel way to detect and predict coagulopathy in trauma patients. A dynamic model, built and tested on thromboelastogram (TEG) data, was used to generate a virtual library of over 160,000 simulated RapidTEGs. The patient-specific parameters are the initial platelet count, platelet activation rate, thrombus growth rate, and lysis rate (P(0), k1, k2, and k3, respectively). METHODS: Patient data from both STAAMP (n = 182 patients) and PAMPer (n = 111 patients) clinical trials were collected. A total of 873 RapidTEGs were analyzed. One hundred sixteen TEGs indicated maximum amplitude (MA) below normal and 466 TEGs indicated lysis percent above normal. Each patient's TEG response was compared against the virtual library of TEGs to determine library trajectories having the least sum-of-squared error versus the patient TEG up to each specified evaluation time ∈ (3, 4, 5, 7.5, 10, 15, 20 minutes). Using 10 nearest-neighbor trajectories, a logistic regression was performed to predict if the patient TEG indicated MA below normal (<50 mm), lysis percent 30 minutes after MA (LY30) greater than 3%, and/or blood transfusion need using the parameters from the dynamic model. RESULTS: The algorithm predicts abnormal MA values using the initial 3 minutes of RapidTEG data with a median area under the curve of 0.95, and improves with more data to 0.98 by 10 minutes. Prediction of future platelet and packed red blood cell transfusion based on parameters at 4 and 5 minutes, respectively, provides equivalent predictions to the traditional TEG parameters in significantly less time. Dynamic model parameters could not predict abnormal LY30 or future fresh-frozen plasma transfusion. CONCLUSION: This analysis could be incorporated into TEG software and workflow to quickly estimate if the MA would be below or above threshold value within the initial minutes following a TEG, along with an estimate of what blood products to have on hand. LEVEL OF EVIDENCE: Therapeutic/Care Management: Level IV.

Sputum and salivary protein biomarkers and point-of-care biosensors for the management of COPD.

Chronic obstructive pulmonary disease (COPD) has become one of the most fatal diseases of the century considering mortality and morbidity levels worldwide. This disease is an inflammatory response to environmental stress and tobacco smoking. Although spirometry is the gold-standard diagnostic test administrated in primary and secondary care, it often exhibits low accuracy in cases of predicting disease worsening and possible bias due to the operator, patient, and conditions. Recent developments in proteomics research suggest that the presence of protein biomarkers can aid in the accurate diagnosis and prediction of disease outcomes. This review presents the cutting-edge research progress in the area of protein biomarkers towards the management of COPD. The literature review was confined to protein biomarkers in saliva and sputum because testing these bodily fluids shows great promise for point-of-care (POC) testing due to its practicality, non-invasiveness and inexpensive handling and sampling. Although it is conclusive that more studies on sputum and saliva are needed, this review studies the promising clinical value of interleukin (IL)-6 and IL-8, matrix metalloproteinase (MMP)-8 and MMP-9, C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and neutrophil elastase (NE). Following the critical analysis of salivary and sputum biomarkers, the recent development of POC biosensors for the multiplexed detection of biomarkers is also reported. Overall, the review aims to explore the possibility for the future development of POC sensors for chronic lung disease management utilizing clinically relevant biomarkers in saliva and sputum.

Confirmation of Parathyroid Tissue: Are Surgeons Aware of New and Novel Techniques?

BACKGROUND: Ex vivo aspiration of parathyroid glands for the measurement of intraoperative parathyroid hormone (IOPTH) levels is a rapid point-of-care method to confirm parathyroid tissue during parathyroidectomy and an alternative to frozen section (FS). This study sought to determine the awareness and utilization of this technique among endocrine surgeons. MATERIALS AND METHODS: A de-identified 12-question survey regarding techniques for intraoperative identification/confirmation of parathyroid tissue and the use of IOPTH monitoring was distributed to all 608 members of the American Association of Endocrine Surgeons. RESULTS: Among the 182 (30%) respondents, FS was the most common primary technique utilized by 115 (63%) respondents to confirm parathyroid tissue; only 12 (7%) utilized ex vivo aspiration, although 78 (42%) were familiar with the technique. Availability and familiarity were the principal reasons for use of the primary technique; the most common barrier was time. Serum IOPTH monitoring was routinely used by 124 (74%). Of respondents who utilized FS, serum IOPTH monitoring was routinely used by 75% (86/115), including 71% (45/63) who reported time as a barrier to FS. Of these 45, only 15 (33%) were familiar with ex vivo parathyroid aspiration. Only 48% of surgeons knew how PTH samples were charged. CONCLUSIONS: FS was the most common method of identification/confirmation of parathyroid tissue. Although most respondents routinely performed IOPTH monitoring, relatively few utilized ex vivo aspiration as a technique for parathyroid identification and less than 50% were familiar with this technique. Broader dissemination about novel techniques such as ex vivo aspiration and cost awareness are recommended.

Geographic accessibility to public health facilities providing tuberculosis testing services at point-of-care in the upper east region, Ghana.

BACKGROUND: In Ghana, limited evidence exists about the geographical accessibility to health facilities providing tuberculosis (TB) diagnostic services to facilitate early diagnosis and treatment. Therefore, we aimed to assess the geographic accessibility to public health facilities providing TB testing services at point-of-care (POC) in the Upper East Region (UER), Ghana. METHODS: We assembled detailed spatial data on all 10 health facilities providing TB testing services at POC, and landscape features influencing journeys. These data were used in a geospatial model to estimate actual distance and travel time from the residential areas of the population to health facilities providing TB testing services. Maps displaying the distance values were produced using ArcGIS Desktop v10.4. Spatial distribution of the health facilities was done using spatial autocorrelation (Global Moran's Index) run in ArcMap 10.4.1. We also applied remote sensing through satellite imagery analysis to map out residential areas and identified locations for targeted improvement in the UER. RESULTS: Of the 13 districts in the UER, 4 (31%) did not have any health facility providing TB testing services. In all, 10 public health facilities providing TB testing services at POC were available in the region representing an estimated population to health facility ratio of 125,000 people per facility. Majority (60%) of the health facilities providing TB testing services in the region were in districts with a total population greater than 100,000 people. Majority (62%) of the population resident in the region were located more than 10 km away from a health facility providing TB testing services. The mean distance ± standard deviation to the nearest public health facility providing TB testing services in UER was 33.2 km ± 13.5. Whilst the mean travel time using a motorized tricycle speed of 20 km/h to the nearest facility providing TB testing services in the UER was 99.6 min ± 41.6. The results of the satellite imagery analysis show that 51 additional health facilities providing TB testing services at POC are required to improve geographical accessibility. The results of the spatial autocorrelation analysis show that the spatial distribution of the health facilities was dispersed (z-score = - 2.3; p = 0.02). CONCLUSION: There is poor geographic accessibility to public health facilities providing TB testing services at POC in the UER of Ghana. Targeted improvement of rural PHC clinics in the UER to enable them provide TB testing services at POC is highly recommended.

Point-of-care influences orchiectomy rates in pediatric patients with testicular torsion.

OBJECTIVES: The objective of this study was to determine whether point-of-care (community hospitals vs. tertiary centers) or treatment-delaying variables (transfer, emergency room [ER] throughput, and distance traveled) affect orchiectomy rates in minors with testicular torsion (TT) using a national database. STUDY DESIGN: This was a retrospective cohort study using prospectively collected data by the Canadian Institute of Health Information (CIHI) between 2010 and 2015. All Canadian male patients in the CIHI database aged <18 years with TT based on International Classification of Diseases (ICD) codes were included, except for those residing in Quebec. Variables collected were age, type of treating institution (community small/medium, community large, or tertiary/academic), transfer for definitive treatment, road distance traveled, and ER throughput. The outcome was testicular loss based on intervention codes for orchiectomy/orchidopexy. Univariable and multivariable analyses were performed using logistic regression. RESULTS: A total of 1713 minors with TT were included. Overall orchiectomy rate was 28%. Most patients (52%) were treated at tertiary hospitals. Small/medium community hospitals depicted the lowest odds of orchiectomy on univariable and multivariable analyses (odds ratio [OR] = 0.54, confidence interval [CI]: 0.37-0.79, p < 0.001); academic hospitals were also associated with a lower odds of orchiectomy than large community ones. Transfer and distance traveled were not associated with the outcome. Age >12 and ER throughput less than 1 h were significantly associated with lower orchiectomy rates. In a subgroup analysis of patients aged <12 years (n = 278), transfer was the only factor associated with increased risk of orchiectomy (OR = 2.41 , CI: 1.09-5.33; p = 0.03). DISCUSSION: This study showed that small and medium community hospitals had the lowest orchiectomy rates in minors with TT in Canada (Figure). However, on multivariable analysis, they performed similarly to tertiary/academic hospitals, with both being superior to large community hospitals. Transfer and distance traveled did not affect orchiectomy rates. Emergency room throughput had a statistically significant association with orchiectomy rates in every analysis and based on the study data would constitute the best target for policies aimed at reducing orchiectomy rates for TT in minors. The main limitation of this study is the inability to evaluate long-term testicular viability of patients not undergoing orchiectomy (i.e., true testicular salvage). CONCLUSIONS: Type of hospital treating facility (point-of-care) affects orchiectomy rates in minors with TT. Small/medium community hospitals depict the lowest orchiectomy rates in Canada. Transfer to another facility for definitive care and distance traveled did not affect orchiectomy rates, except in a subgroup analysis of prepubertal boys. Longer ER throughput and prepubertal age were consistently associated with loss of the testicle.

Correlation between sodium, potassium, hemoglobin, hematocrit, and glucose values as measured by a laboratory autoanalyzer and a blood gas analyzer.

INTRODUCTION: Blood gas analyzers can be alternatives to laboratory autoanalyzers for obtaining test results in just a few minutes. We aimed to find out whether the results from blood gas analyzers are reliable when compared to results of core laboratory autoanalyzers. MATERIALS AND METHODS: This retrospective, single-centered study examined the electronic records of patients admitted to the emergency department of a tertiary care teaching hospital between May 2014 and December 2017. Excluded from the study were patients under 18 years old, those lacking data, those who had any treatment before the laboratory tests, those whose venous gas results were reported more than 30 minutes after the blood sample was taken and for whom any of the laboratory tests were performed at a different time, and recurrent laboratory results from a single patient. RESULTS: Laboratory results were analyzed from a total of 31,060 patients. The correlation coefficients for sodium, potassium, hemoglobin, hematocrit, and glucose levels measured by a blood gas analyzer and a laboratory autoanalyzer were 0.725, 0.593, 0.982, 0.958, and 0.984, respectively; however, there were no good, acceptable agreement limits for any of the parameters. In addition, these results did not change according to the different pH stages (acidosis, normal pH and alkalosis). CONCLUSION: The two types of measurements showed a moderate correlation for sodium and potassium levels and a strong correlation for glucose, hemoglobin, and hematocrit levels, but none of the levels had acceptable agreement limits. Clinicians should be aware of the limitations of blood gas analyzer results.

How closely do blood gas electrolytes and haemoglobin agree with serum values in adult emergency department patients: An observational study.

OBJECTIVE: The aims of this study were to establish the bias (mean difference) and 95% limits of agreement (LoA) between electrolyte values (sodium and potassium) and haemoglobin between whole blood analysed by the ED resuscitation room blood gas analyser and specimens analysed using standard techniques in the central hospital laboratory and to determine the proportion of analyses falling outside defined clinically acceptable LoA and pathology expert defined standards. METHODS: Prospective cohort study. Paired blood gas analyser and laboratory samples taken no more than 10 min apart were included. The primary outcome of interest was bias and 95% LoA by Bland-Altman analysis. Subgroup analyses for values outside the normal range were also conducted. RESULTS: Three hundred and fifty-two sample pairs were included in the analysis. For sodium concentration the bias was 0.6 mmol/L (95% LoA -3.3 to 4.6 mmol/L). For potassium concentration the bias was 0.21 mmol/L (95% LoA -0.36 to 0.79 mmol/L). For haemoglobin concentration the bias was -1.6 g/dL (95% LoA -10.2 to 6.9 g/dL). For sodium and haemoglobin concentrations, >95% of results fell within the defined clinically acceptable limits. For potassium concentration, >90% of results fell within the defined clinically acceptable limits. In general, serum sodium and potassium concentrations were slightly higher than blood gas levels and for haemoglobin serum levels were slightly lower. CONCLUSION: Agreement between blood gas analysis and laboratory analysis for sodium, potassium and haemoglobin concentrations shows acceptable agreement for use in time critical clinical decision-making in ED.

Factors Predicting Ventriculostomy Revision at a Large Academic Medical Center.

BACKGROUND: Freehand bedside ventriculostomy placement can result in catheter malfunction requiring a revision procedure and cause significant patient morbidity. We performed a single-center retrospective review to assess factors related to this complication. METHODS: Using an administrative database and chart review, we identified 101 first-time external ventricular drain placements performed at the bedside. We collected data regarding demographics, medical comorbidities, complications, and catheter tip location. We performed univariate and multivariate statistical analyses using MATLAB. We corrected for multiple comparisons using the false discovery rate (FDR) procedure. RESULTS: Multivariate regression analyses revealed that revision procedures were more likely to occur after drain blockage (odds ratio [OR] 17.9) and hemorrhage (OR 10.3, FDR-corrected P values < 0.01, 0.05, respectively). Drain blockage was less frequent after placement in an "optimal location" (ipsilateral ventricle or near foramen of Monroe; OR 0.09, P = 0.009, FDR-corrected P < 0.03) but was more likely to occur after placement in third ventricle (post-hoc P values < 0.015). Primary diagnoses included subarachnoid hemorrhage (n = 30, 29.7%), intraparenchymal hemorrhage with intraventricular extravasation (n = 24, 23.7%), tumor (n = 20, 19.8%), and trauma (n = 17, 16.8%). Most common complications included drain blockage (n = 12, 11.8%) and hemorrhage (n = 8, 7.9%). In total, 16 patients underwent at least 1 revision procedure (15.8%). CONCLUSIONS: Bedside external ventricular drain placement is associated with a 15% rate of revision, that typically occurred after drain blockage and postprocedure hemorrhage. Optimal placement within the ipsilateral frontal horn or foramen of Monroe was associated with a reduced rate of drain blockage.

Patient awareness, willingness, and barriers to point-of-care hepatitis C screening in community pharmacy.

OBJECTIVES: To determine patients' awareness of the screening recommendations for hepatitis C virus (HCV) in "Baby Boomers," to assess patients' willingness to receive a point-of-care HCV screening test in the pharmacy, and to determine patients' barriers to receiving a point-of-care HCV screening test in a community pharmacy. METHODS: An anonymous 12-question survey was developed. Five shareholder pharmacies of American Pharmacy Services Corporation (APSC) volunteered to participate. Surveys were mailed to participating pharmacies with instructions to distribute to patients born in 1945 to 1965 at the pharmacy point-of-sale. Data were collected over a 12-week period from October 2016 to January 2017. Completed surveys were collected by participating pharmacies and mailed to the primary investigator. Data were analyzed with the use of descriptive statistics. RESULTS: Ninety-five eligible surveys were returned and analyzed. A majority of respondents were female (63.00%) and held a bachelor degree or higher (63.16%); 38.95% of patients were aware of HCV age-based risk factors and screening recommendations. Only 9.80% of patients were aware of the fingerstick point-of-care testing (POCT) option for HCV. Nearly three-fourths (71.70%) were willing to receive POCT at a community pharmacy. A majority of patients (65.52%) were unwilling to pay an amount that would cover the cost of testing. Descriptive statistics, including a Pearson chi-square test, were used to analyze the data. Significant differences in the distribution of the percentages of people willing to receive testing and to pay for testing were found among levels of annual household income. CONCLUSION: A majority of patients are willing to receive POCT at a community pharmacy. Patients were unwilling to pay for testing, however, so pharmacies looking to offer point-of-care HCV screening would need to secure further financial resources, such as insurance reimbursement or grant funding, for this service to be financially feasible.

Airway physical examination tests for detection of difficult airway management in apparently normal adult patients.

BACKGROUND: The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear. OBJECTIVES: The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. SEARCH METHODS: We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals, conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results. SELECTION CRITERIA: We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard. Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target condition was difficult airway, with one of the following reference standards: difficult face mask ventilation, difficult laryngoscopy, difficult tracheal intubation, and failed intubation. DATA COLLECTION AND ANALYSIS: We performed screening and selection of the studies, data extraction and assessment of methodological quality (using QUADAS-2) independently and in duplicate. We designed a Microsoft Access database for data collection and used Review Manager 5 and R for data analysis. For each index test and each reference standard, we assessed sensitivity and specificity. We produced forest plots and summary receiver operating characteristic (ROC) plots to summarize the data. Where possible, we performed meta-analyses to calculate pooled estimates and compare test accuracy indirectly using bivariate models. We investigated heterogeneity and performed sensitivity analyses. MAIN RESULTS: We included 133 (127 cohort type and 6 case-control) studies involving 844,206 participants. We evaluated a total of seven different prespecified index tests in the 133 studies, as well as 69 non-prespecified, and 32 combinations. For the prespecified index tests, we found six studies for the Mallampati test, 105 for the modified Mallampati test, six for the Wilson risk score, 52 for thyromental distance, 18 for sternomental distance, 34 for the mouth opening test, and 30 for the upper lip bite test. Difficult face mask ventilation was the reference standard in seven studies, difficult laryngoscopy in 92 studies, difficult tracheal intubation in 50 studies, and failed intubation in two studies. Across all studies, we judged the risk of bias to be variable for the different domains; we mostly observed low risk of bias for patient selection, flow and timing, and unclear risk of bias for reference standard and index test. Applicability concerns were generally low for all domains. For difficult laryngoscopy, the summary sensitivity ranged from 0.22 (95% confidence interval (CI) 0.13 to 0.33; mouth opening test) to 0.67 (95% CI 0.45 to 0.83; upper lip bite test) and the summary specificity ranged from 0.80 (95% CI 0.74 to 0.85; modified Mallampati test) to 0.95 (95% CI 0.88 to 0.98; Wilson risk score). The upper lip bite test for diagnosing difficult laryngoscopy provided the highest sensitivity compared to the other tests (P < 0.001). For difficult tracheal intubation, summary sensitivity ranged from 0.24 (95% CI 0.12 to 0.43; thyromental distance) to 0.51 (95% CI 0.40 to 0.61; modified Mallampati test) and the summary specificity ranged from 0.87 (95% CI 0.82 to 0.91; modified Mallampati test) to 0.93 (0.87 to 0.96; mouth opening test). The modified Mallampati test had the highest sensitivity for diagnosing difficult tracheal intubation compared to the other tests (P < 0.001). For difficult face mask ventilation, we could only estimate summary sensitivity (0.17, 95% CI 0.06 to 0.39) and specificity (0.90, 95% CI 0.81 to 0.95) for the modified Mallampati test. AUTHORS' CONCLUSIONS: Bedside airway examination tests, for assessing the physical status of the airway in adults with no apparent anatomical airway abnormalities, are designed as screening tests. Screening tests are expected to have high sensitivities. We found that all investigated index tests had relatively low sensitivities with high variability. In contrast, specificities were consistently and markedly higher than sensitivities across all tests. The standard bedside airway examination tests should be interpreted with caution, as they do not appear to be good screening tests. Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties. Given the paucity of available data, future research is needed to develop tests with high sensitivities to make them useful, and to consider their use for screening difficult face mask ventilation and failed intubation. The 27 studies in 'Studies awaiting classification' may alter the conclusions of the review, once we have assessed them.

Household point of care CD4 testing and isoniazid preventive therapy initiation in a household TB contact tracing programme in two districts of South Africa.

BACKGROUND: In South Africa, TB household contact tracing provides an opportunity for increased TB and HIV case finding. We aimed to determine the effect of two new potential interventions for TB contact tracing programmes: Point of Care CD4 (PoC CD4) on HIV linkage to care and household Isoniazid Preventive Therapy (IPT) provision on uptake and retention of IPT. METHODS: A pragmatic, three-arm, cluster-randomized trial was undertaken. TB Household contacts were randomised to 3 arms: 1) Standard of Care TB and HIV testing (SOC); 2) SOC with POC CD4 for those testing HIV positive; 3) SOC with POC CD4 and IPT for eligible household members. Linkage to care within 90 days was assessed either through patient visits (at 10 weeks and 6 months) or via telephonic contact. RESULTS: 2,243 index TB patients and 3,012 contacts (64,3% female, median age 30 years) were enrolled. On self-report, 26(1.2%) were currently receiving TB treatment and 1816 (60.3%) reported a prior HIV test. HIV testing uptake was 34.7% in the SoC arm, 40.2% in the PoC CD4 arm (RR1.16, CI 0.99-1.36, p-value = 0.060) and 39.9% in the PoC CD4 + HH-IPT arm (RR = 1.15, CI 0.99-1.35, p-value = 0.075). Linkage to care within 3 months was 30.8% in the SoC arm and 42.1% in the POC CD4 arms (RR 1.37; CI: 0.68-2.76, p-value = 0.382). 20/21 contacts (95.2%) initiated IPT in the PoC CD4 + HH-IPT arm, compared to 3/20 (15.0%) in the PoC CD4 arm (p = 0.004; p-value from Fisher's exact test < 0.001). Among 3,008 contacts screened for tuberculosis, 15 (3.4%) had bacteriologically confirmed TB with an overall yield of TB of 0.5% (95% CI: 0.3%, 0.8%). CONCLUSIONS: Household PoC CD4 testing and IPT initiation is feasible. There was only weak evidence that PoCCD4 led to a small increase in HCT uptake and no evidence for an increase in linkage-to-care. IPT initiation and completion was increased by the household intervention. Although feasible, these interventions had low impact due to the low uptake of HIV testing in households.

Blood transfusion management in the severely bleeding military patient.

PURPOSE OF REVIEW: Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. RECENT FINDINGS: Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. SUMMARY: Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting.

Level of agreement between laboratory and point-of-care prothrombin time in patients after stopping or continuation of acenocoumarol anticoagulation: A comparison of diagnostic accuracy.

BACKGROUND: Procedures requiring optimisation of the coagulation status of patients using vitamin K antagonists are frequently postponed due to the late availability of laboratory international normalised ratio (INR) test results. A point-of-care (POC) alternative may facilitate early decision-making in peri-operative patients. OBJECTIVES: To assess the level of agreement between the POC-INR and the laboratory INR in patients who continue or stop vitamin K antagonists to determine whether the POC test may be a good alternative to the laboratory INR. DESIGN: Study of diagnostic accuracy. SETTING: Single-centre study at Zaans Medical Centre, The Netherlands. PATIENTS: Included patients were scheduled for cardioversion (these continued taking vitamin K antagonists), or a surgical procedure (these stopped taking vitamin K antagonists). MAIN OUTCOME MEASURES: The level of agreement and clinical acceptability of the laboratory and POC-INR results, evaluated by Bland-Altman analysis and error grid analysis. RESULTS: The surgical and cardioversion groups consisted of 47 and 46 patients, respectively. The bias in the INR in the surgical group was -0.12 ±â€Š0.09 with limits of agreement of -0.29 to 0.05, whereas the cardioversion group showed a bias in the INR of -0.22 ±â€Š0.36 with limits of agreement from -0.93 to 0.48. The percentage errors between methods in the surgical and cardioversion groups were 16 and 21%, respectively. Error grid analysis showed that the diagnostic accuracy of the POC prothrombin time is clinically acceptable as the difference did not lead to a different clinical decision in the surgical group with INR values less than 1.8. CONCLUSION: The current study shows a good level of agreement and clinical accuracy between the laboratory and POC-INR in patients who stopped anticoagulation intake for surgery. However, in patients who continued their anticoagulation therapy, the agreement between the two methods was less accurate.

The performance of the Alere HIV combo point-of-care test on stored serum samples; useful for detection of early HIV-1 infections?

INTRODUCTION: The Alere HIV-1/2 Antigen/Antibody Combo point-of-care test is a commercially available 4th-generation rapid test for the diagnosis of HIV infection, including acute infection. We evaluated the sensitivity of this test in samples from patients with acute, recent or chronic HIV-1 infection. METHODS: A validation of the test was performed using 89 HIV-positive serum samples collected in 2008-2016, that were stored at -20°C. Twenty-three samples were only p24-positive (acute infection); 49 samples were antibody-positive and p24-positive (recent infection); 17 samples were only antibody-positive (chronic infection). HIV infection was confirmed by standard-of-care assays and PCR. Samples came from patients attending an outpatient clinic for STDs at the Public Health Department and from patients within the Erasmus Medical Center, Rotterdam, the Netherlands. RESULTS: The overall sensitivity of the test for diagnosing HIV infection based on detection of p24 antigen and/or antibodies was 92% (95% CI 86% to 98%) (82/89). In acute sera with only p24 antigen positivity, the sensitivity of the test decreased to 65% (95% CI 46% to 85%) (15/23). When both antibody and antigen testing were positive, the p24 sensitivity was only 24% (95% CI 12% to 36%) (12/49), but in these sera the final test result was positive in all sera (49/49) due to the positive antibody component. CONCLUSIONS: In a laboratory setting, this test has an overall sensitivity of 92% to detect any stage of HIV-1 infection using sera specimens. It performs relatively well in detecting early HIV and may be beneficial as an initial screening in patients with a recent exposure to HIV. Additional testing in a laboratory setting remains mandatory as a proportion of acute HIV-1 infections are missed with this test.

Smartphone Use by Nurses in Acute Care Settings.

The use of smartphones in acute care settings remains controversial due to security concerns and personal use. The purposes of this study were to determine (1) the current rates of personal smartphone use by nurses in acute care settings, (2) nurses' preferences regarding the use of smartphone functionality at work, and (3) nurse perceptions of the benefits and drawbacks of smartphone use at work. An online survey of nurses from six acute care facilities within one healthcare system assessed the use of personal smartphones in acute care settings and perceptions of the benefits and drawbacks of smartphone use at work. Participants (N = 735) were primarily point-of-care nurses older than 31 years. Most participants (98%) used a smartphone in the acute care setting. Respondents perceived the most common useful and beneficial smartphone functions in acute care settings as allowing them to access information on medications, procedures, and diseases. Participants older than 50 years were less likely to use a smartphone in acute care settings and to agree with the benefits of smartphones. There is a critical need for recognition that smartphones are used by point-of-care nurses for a variety of functions and that realistic policies for smartphone use are needed to enhance patient care and minimize distractions.

Innovative tools and approaches to end the transmission of Mycobacterium leprae.

Leprosy control has seen little innovation and only limited progress in the past decade. However, research on the disease has increased and important innovations are underway. Here, we comment on efforts to develop tools and approaches to detect leprosy and to stop the transmission of Mycobacterium leprae, the causative bacillus of the disease. The tracing and screening of contacts of known patients with leprosy promises to strengthen early diagnosis, while preventive chemotherapy will reduce the risk of contacts developing the disease by 50-60% within 2 years of administration. Until now, diagnosis has been mainly based on the presence of signs and symptoms, but efforts are underway to develop inexpensive, reliable, point-of-care tests to diagnose infection. Development of a leprosy-specific vaccine that boosts long-lasting T-cell responses is also a research objective. As for launching a programme to interrupt transmission, two interlinked tools-epidemiological modelling and the concept of an investment case-are being developed to explore the feasibility and costs of such a programme and its overall effect on individuals and society. We believe that sustained innovation is needed and that only a combination of tools and approaches holds promise to end M leprae transmission.